Title 30: Professions and Occupations Part 2630 Collaboration/Consultation Part 2630 Chapter 1: Collaboration/Consultation with Nurse Practitioners Rule 1.1 Scope. These rules apply to all individuals licensed to practice medicine or osteopathic medicine in the state of Mississippi. Rule 1.2 Definitions. For the purpose of Part 2630, Chapter 1 only, the following terms have the meanings indicated: A. Physician means any person licensed to practice medicine or osteopathic medicine in the state of Mississippi who holds an unrestricted license or whose practice or prescriptive authority is not limited as a result of voluntary surrender or legal/regulatory order. B. Free Standing Clinic means a clinic or other facility wherein patients are treated by a nurse practitioner, which is more than fifteen (15) miles away from the primary office of the collaborative/consultative physician. Excluded from this definition are all licensed hospitals, state health department facilities, federally qualified community health clinics and volunteer clinics. C. Primary Office means the usual practice location of a physician and being the same location reported by that physician to the Mississippi State Board of Medical Licensure and the United States Drug Enforcement Administration. D. Collaborating/Consulting Physician means a physician who, pursuant to a duly executed protocol has agreed to collaborate/consult with a nurse practitioner. E. Nurse Practitioner means any person licensed to practice nursing in the state of Mississippi and certified by the Mississippi Board of Nursing to practice in an expanded role as a nurse practitioner. F. Advanced Practice Registered Nurse includes all nurse practitioners, certified nurse midwives and certified registered nurse anesthetists. Rule 1.3 Board Review. Physicians who wish to collaborate/consult with a nurse practitioner who plans or anticipates practicing in a free standing clinic, must first (a) appear personally or by telephone before the Mississippi State Board of Medical Licensure and/or the Joint Committee of the Board of Medical Licensure and the Board of Nursing if the Board of Medical Licensure determines that the collaborative/consultative relationship may not be approved absent action from the Joint Committee, (b) present and discuss the protocol, and (c) obtain approval from the Board to act as a collaborating/consulting physician. The facts and matters to be considered by the Board shall include, but are not limited to, how the collaborating/consulting physician and nurse practitioner plan to implement the protocol, the method and manner of collaboration, consultation, and referral. 1
The requirement for Board appearance and approval set forth in the preceding paragraph also applies to any physician collaborating/consulting with a nurse practitioner who later moves to a free standing clinic under an existing protocol. Where a nurse practitioner is practicing in a free standing clinic pursuant to an existing protocol as of the effective date of this regulation, the requirements of personal appearance or telephone interview and Board approval set forth in the paragraph above shall not be required until the next succeeding renewal date for said certificate as required by the Mississippi State Board of Nursing. Where two or more physicians anticipate executing a protocol to collaborate/consult with a nurse practitioner practicing in a free standing clinic, it shall not be necessary that all of the physicians personally appear before the Mississippi State Board of Medical Licensure as required in the preceding paragraph. In this situation, the physician who will bear the primary responsibility for the collaboration/consultation with the nurse practitioner shall make the required personal appearance or telephone interview. Each collaborative/consultative relationship shall include and implement a formal quality improvement program which shall be maintained on site and shall be available for inspection by representatives of the Mississippi State Board of Medical Licensure. The quality assurance/quality improvement program shall consist of: A. Review by collaborative physician of a random sample of charts that represent 10% or 20 charts, whichever is less, of patients seen by the nurse practitioner every month. Charts should represent the variety of patient types seen by the nurse practitioner. Patients that the nurse practitioner and collaborating physician have consulted on during the month will count as one chart review. B. The nurse practitioner shall maintain a log of charts reviewed which include the identifier for the patient s charts, reviewers names, and dates of review. C. Each nurse practitioner shall meet face to face with a collaborating physician once per quarter for the purpose of quality assurance and this meeting should be documented. Rule 1.4 Collaborative/Consultative Relationships. Physicians with collaborative relationships with APRN must ensure backup physician coverage when the primary collaborative physician is unavailable. The backup physician must be on APRN protocol. In the event of death, disability (physical/mental), or relocation, which would result in the APRN not having a collaborative physician, the APRN has the duty to immediately notify the Mississippi Board of Nursing as jointly agreed by the Mississippi Board of Nursing and the Mississippi Board of Medical Licensure. The Nursing Board will then immediately notify the Mississippi State Board of Medical Licensure. In order that patients may continue to be treated without interruption of care, the APRN may be allowed to continue to practice for a 90-day grace period while the APRN attempts to secure a collaborative physician without such practice being considered the practice of medicine. The Mississippi State Board of Medical Licensure or its designee, will serve as the APRN s 2
collaborative physician with the agreement of the Mississippi Board of Nursing. The Mississippi State Board of Medical Licensure and the Mississippi State Board of Nursing will assist the APRN in their attempt to secure a collaborative physician. If a collaborative physician has not been secured at the end of the 90-day grace period, an additional 90-day extension may be granted by mutual agreement of the Executive Committee of the Mississippi Board of Nursing and the Executive Committee of the Mississippi State Board of Medical Licensure. During this additional 90-day extension, the above described collaborative agreement will continue. The APRN will not be allowed to practice until the previously described collaborative arrangement with the Mississippi State Board of Medical Licensure is agreed upon. Rule 1.4 Violation of Rules. Any violation of the rules as enumerated above shall constitute unprofessional conduct in violation of Mississippi Code, Section 73-25-29(8). Rule 1.5 Effective Date of Regulation. The above rules pertaining to collaborating/consulting physicians shall become effective September 21, 1991. Amended May 19, 2005. Amended March 13, 2009. Amended November 19, 2009. 3
Title 30: Professions and Occupations Part 2630 Collaboration/Consultation Part 2630 Chapter 1: Collaboration/Consultation with Nurse Practitioners Rule 1.1 Scope. These rules apply to all individuals licensed to practice medicine or osteopathic medicine in the state of Mississippi. These rules apply to all individuals licensed to practice medicine or osteopathic medicine in the state of Mississippi. Because discipline may be imposed for failure to meet the standard of practice in connection with collaborative agreement with any advanced practice registered nurse (APRN), the Board of Medical Licensure has determined that it is reasonable, necessary and in the public interest to adopt the following rules detailing what it considers to be the standard of practice. These rules are to inform and educate physicians in collaborative relationships as to what the Board of Medical Licensure considers to be the responsibilities of such physicians. These rules intend to be practical and flexible enough to address a variety of situations and specialties. The Board of Medical Licensure does not intend to restrict patient access to essential healthcare in the state of Mississippi. Rule 1.2 Definitions. For the purpose of Part 2630, Chapter 1 only, the following terms have the meanings indicated: A. Physician means any person licensed to practice medicine or osteopathic medicine in the state of Mississippi who holds an unrestricted license or whose practice or prescriptive authority is not limited as a result of voluntary surrender or legal/regulatory order. Advanced Practice Registered Nurse (APRN) is a person who is licensed or holds the privilege to practice under Miss. Code Ann. Section 73-15-5, and who is nationally certified as an advanced practice registered nurse or in a specialized nursing practice which includes certified nurse midwives (CNM), certified nurse anesthetists (CRNA), clinical nurse specialists (CNS) and certified nurse practitioners (CNP). B. Free Standing Clinic means a clinic or other facility wherein patients are treated by a nurse practitioner, which is more than fifteen (15) miles away from the primary office of the collaborative/consultative physician. Excluded from this definition are all licensed hospitals, state health department facilities, federally qualified community health clinics and volunteer clinics. Physician means any person licensed to practice medicine or osteopathic medicine in the state of Mississippi who holds an unrestricted license or whose practice or prescriptive authority is not limited as a result of voluntary surrender or legal/regulatory order. C. Primary Office means the usual practice location of a physician and being the same location reported by that physician to the Mississippi State Board of Medical Licensure and the United States Drug Enforcement Administration. Primary Collaborating Physician means a physician who, pursuant to a duly executed protocol, has agreed to adhere to the responsibilities implied by the collaborative agreement with an APRN as outlined in 73-43-11. This responsibility includes, but is not limited to, adherence to the Quality Assurance Program set out in these rules. 4
D. Collaborating/Consulting Physician means a physician who, pursuant to a duly executed protocol has agreed to collaborate/consult with a nurse practitioner. Secondary Collaborating Physician ( Back-up Physician ) is a physician who, pursuant to a duly executed collaborative agreement, agrees to perform the duties of the primary collaborating physician, including adherence to these rules, when the primary collaborating physician is unavailable. The classification secondary physician may also be applied when the physician is collaborating with a nurse practitioner who is working 20 hours or less a week for a clinic but has a full-time primary physician in collaboration at another site. When the secondary collaborating physician is acting as the primary all of the following rules apply. E. Nurse Practitioner means any person licensed to practice nursing in the state of Mississippi and certified by the Mississippi Board of Nursing to practice in an expanded role as a nurse practitioner. Collaborative Agreement means a written agreement between a physician, either primary or secondary as defined above, and an APRN. The collaborative agreement must be individualized to the specific collaborative practice. F. Acute Care Facility means a hospital facility in which patients with acute medical conditions (e.g. cardiac, pulmonary, stroke, etc.) are being cared for by APRNs. G. Advanced Practice Registered Nurse includes all nurse practitioners, certified nurse midwives and certified registered nurse anesthetists. Board means the Mississippi State Board of Medical Licensure. Rule 1.3 Board Review. Physicians who wish to collaborate/consult with a nurse practitioner who plans or anticipates practicing in a free standing clinic, must first (a) appear personally or by telephone before the Mississippi State Board of Medical Licensure and/or the Joint Committee of the Board of Medical Licensure and the Board of Nursing if the Board of Medical Licensure determines that the collaborative/consultative relationship may not be approved absent action from the Joint Committee, (b) present and discuss the protocol, and (c) obtain approval from the Board to act as a collaborating/consulting physician. The facts and matters to be considered by the Board shall include, but are not limited to, how the collaborating/consulting physician and nurse practitioner plan to implement the protocol, the method and manner of collaboration, consultation, and referral. The requirement for Board appearance and approval set forth in the preceding paragraph also applies to any physician collaborating/consulting with a nurse practitioner who later moves to a free standing clinic under an existing protocol. Where a nurse practitioner is practicing in a free standing clinic pursuant to an existing protocol as of the effective date of this regulation, the requirements of personal appearance or telephone interview and Board approval set forth in the paragraph above shall not be required until the next succeeding renewal date for said certificate as required by the Mississippi State Board of Nursing. 5
Where two or more physicians anticipate executing a protocol to collaborate/consult with a nurse practitioner practicing in a free standing clinic, it shall not be necessary that all of the physicians personally appear before the Mississippi State Board of Medical Licensure as required in the preceding paragraph. In this situation, the physician who will bear the primary responsibility for the collaboration/consultation with the nurse practitioner shall make the required personal appearance or telephone interview. Each collaborative/consultative relationship shall include and implement a formal quality improvement program which shall be maintained on site and shall be available for inspection by representatives of the Mississippi State Board of Medical Licensure. The quality assurance/quality improvement program shall consist of: A. Review by collaborative physician of a random sample of charts that represent 10% or 20 charts, whichever is less, of patients seen by the nurse practitioner every month. Charts should represent the variety of patient types seen by the nurse practitioner. Patients that the nurse practitioner and collaborating physician have consulted on during the month will count as one chart review. B. The nurse practitioner shall maintain a log of charts reviewed which include the identifier for the patient s charts, reviewers names, and dates of review. Each nurse practitioner shall meet face to face with a collaborating physician once per quarter for the purpose of quality assurance and this meeting should be documented. Rule 1.3 Requirements for Collaborating Physicians. Primary and secondary collaborating physicians must: A. hold a current unrestricted license in the state of Mississippi and actively provide direct patient care at least eight (8) hours weekly; B. notify the Board within seven (7) working days of entering into or termination of any collaborative agreement; C. insure that the primary collaborative physician(s) name(s) is/are displayed for public view at the APRN s practice site; and D. enter into a collaborative agreement with the APRN, which is written, signed and dated by both the APRN and physician, and which must: 1. remain in the practice site of the collaborating physician should there be a site visit by the Board; 2. define the scope of practice, including mutually agreed upon collaborative agreements and guidelines for the healthcare provided; 3. agree upon medication formulary to be used by APRN and physician in practice. The collaborative physician has the right to use the Mississippi Prescription Monitoring Program to review the APRN s controlled substance prescribing practices; 4. describe the individual and shared responsibilities of the APRN and physician; 5. be reviewed and updated annually by the physician and the APRN; and 6. set out a procedure for handling patient emergencies, unexpected outcomes or other urgent practice situations. A physician shall not enter into a collaborative agreement with an APRN whose training and practice is not compatible with that of the physician (it is recognized and accepted practice that 6
surgeons, obstetricians and dentists have collaborative arrangements with CRNAs). The collaborative agreement shall not include medications the physician does not use in his or her current practice and about which the physician is not knowledgeable and competent. Before entering into a collaborative agreement, a physician should consider the following when determining the degree of autonomy the agreement provides: A. the physician s personal knowledge and ability to provide the time to the collaborative agreement; B. the type of practice; C. the scope of practice of the APRN; D. the educational training and experience of the APRN; E. the geographic location of the physician s practice and the practice of the APRN and their ability to consult in a manner that assures patient safety; and F. the technology available to the physician and APRN to allow effective communication and consultation. Physicians are prohibited from entering into a collaborative agreement with an APRN whose practice location is greater than forty (40) miles from the physician s practice site, unless a waiver is expressly granted by the Board for that particular collaborative agreement. However, a collaborative physician (primary or secondary) must be within 40 miles from the actively practicing APRN. Collaborative agreements which have previously been granted as waivers at the time of adoption of these rules will continue to be exempt from this requirement. Anytime a collaborating physician is working with an APRN who is working in and/or staffing an emergency room the collaborative physician (primary or secondary) must be physically present in the building or no more than five (5) minutes from the facility. An exception to this policy would be Board approved telemanagement arrangements. Anytime a collaborating physician is working with an APRN who is working in and/or providing care in an acute care facility, there must be evidence reflected in the patient s chart that a collaborative physician has seen and examined the patient within twelve (12) hours of the APRN seeing the patient. Physicians are prohibited from entering into primary collaborative agreements with more than four (4) APRN s at any one time unless a waiver is expressly granted by the Board for that particular collaborative agreement. However, a physician may be in collaboration as the secondary physician on four (4) additional collaborative agreements and no QA, as defined under Rule 1.4, will be required for these additional APRNs. A secondary physician status may be given to a physician who is collaborating with up to two (2) APRNs who are working less than 20 hours per week at another clinic not in the same practice as the APRN s primary place of work. A QA review will be required quarterly. Collaborative agreements which have previously been granted such waivers at the time of adoption of these rules will continue to be exempt from this requirement. The Board will consider the factors listed above, as well as any other factors that the Board 7
deems relevant, in determining whether to grant a waiver. Such waivers may be granted to medical practices with multiple physicians including, but not limited to, the following settings: A. emergency rooms; B. intensive care units; C. Labor epidural services on Obstetrical Suites D. State Department of Health; E. State Department of Mental Health; and F. federally funded health systems (e.g. FQHCs, VAMCs). Physicians shall complete a questionnaire pertaining to APRNs upon initial licensure and during each annual renewal process. Rule 1.4 Collaborative/Consultative Relationships. Physicians with collaborative relationships with APRN must ensure backup physician coverage when the primary collaborative physician is unavailable. The backup physician must be on APRN protocol. In the event of death, disability (physical/mental), or relocation, which would result in the APRN not having a collaborative physician, the APRN has the duty to immediately notify the Mississippi Board of Nursing as jointly agreed by the Mississippi Board of Nursing and the Mississippi Board of Medical Licensure. The Nursing Board will then immediately notify the Mississippi State Board of Medical Licensure. In order that patients may continue to be treated without interruption of care, the APRN may be allowed to continue to practice for a 90-day grace period while the APRN attempts to secure a collaborative physician without such practice being considered the practice of medicine. The Mississippi State Board of Medical Licensure or its designee, will serve as the APRN s collaborative physician with the agreement of the Mississippi Board of Nursing. The Mississippi State Board of Medical Licensure and the Mississippi State Board of Nursing will assist the APRN in their attempt to secure a collaborative physician. If a collaborative physician has not been secured at the end of the 90-day grace period, an additional 90-day extension may be granted by mutual agreement of the Executive Committee of the Mississippi Board of Nursing and the Executive Committee of the Mississippi State Board of Medical Licensure. During this additional 90-day extension, the above described collaborative agreement will continue. The APRN will not be allowed to practice until the previously described collaborative arrangement with the Mississippi State Board of Medical Licensure is agreed upon. Rule 1.4 Quality Assurance Program. Physicians entering into collaborative agreements shall implement a quality assurance program which shall include: A. Review by the primary collaborating physician of a random sample of charts that represent 10% or 20 charts, whichever is less, of patients seen by the APRN every month. Charts should represent the variety of patient types seen by the nurse practitioner. Each patient encounter that the nurse practitioner and collaborating physician have consulted on during the month will count as one chart review. B. Review of the controlled medications prescribed by the APRN revealed in the chart review. The physician may also make review through the Board of Pharmacy 8
Prescription Monitoring Program. C. The primary collaborating physician shall meet face to face with the APRN once per quarter for the purpose of quality assurance and this meeting should be documented. D. Secondary physicians for APRNs who work less than 20 hours per week at a clinic shall meet face to face with the APRN once per quarter for the purpose of quality assurance and this meeting should be documented. E. The collaborating physician must insure that the APRN maintains a log of charts reviewed, including: 1. the identifier for the patients charts; 2. reviewers names; and 3. dates of review. Rule 1.5 Disability of Primary Collaborating Physician. In the event of death, disability (physical/mental) or unanticipated relocation of a primary collaborating physician, the secondary collaborating physician shall act as the primary collaborating physician. In the event the APRN has no secondary collaborating physician, the APRN must notify the Mississippi Board of Nursing, which will then immediately notify the Board. In such cases, the APRN may continue to practice for a 90-day grace period while the APRN attempts to secure a primary collaborating physician without such practice being considered the practice of medicine. The Board or its designee, will serve as the APRN s primary collaborating physician with the approval of the Mississippi Board of Nursing. The Board and the Mississippi State Board of Nursing will assist the APRN in their attempt to secure a primary collaborating physician. If a primary collaborating physician has not been secured at the end of the 90-day grace period, an additional 90-day extension may be granted by mutual agreement of the Executive Committee of the Board of Nursing and the Executive Committee of the Board. During this additional 90-day extension, the above described collaborative agreement will continue. The APRN will not be allowed to practice until the previously described collaborative arrangement with the Board is agreed upon. The Quality Assurance process that was in place will be continued by the Board of Medical Licensure during the extension. Rule 1.46 Violation of Rules. Any violation of the rules as enumerated above shall constitute unprofessional conduct in violation of Mississippi Code, Section 73-25-29(8). Rule 1.57 Effective Date of Regulation. The above rules pertaining to collaborating/consulting physicians shall become effective September 21, 1991. Amended May 19, 2005. Amended March 13, 2009. Amended November 19, 2009. 9